Correction of refractive eye

errors in adults – Part II: laser

surgery and intraocular lenses

CA-RVB, 17th December 2013

C.Obyn, Y. Smit, P. Post, L. Kohn, N. Defourny, W. Christiaens, D. Paulus

2nd part of larger study

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Prevalence of errors and perceptions • Telephone survey and focus groups

Surgical techniques • Effectiveness, safety, costs, patient perspective

Legal aspects of extramural centres

Methods

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Patients

qualitative interview 36 patients

Scientific studies

RCTs and observational studies

Experts

Expert meetings and interviews

Cost calculation

Surface ablation

PRK, LASEK, epiLASIK*

Deep ablation

LASIK, FemtoLASIK*, SMILE *

* RECENT

Posterior chamber

Anterior chamber

Clear lens exchange (as in cataract operation)

Laser procedures

Phakic intraocular lenses

Interventions

pIOL

Phakic Intraocular lensLASIK

Source illustrations: www.lasik.fr ; www.wpclipart.com

Indications

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Range of application

Limit range

6 8 10 Diopter

myopia

astigmatism

hyperopia

5 4

myopia

astigmatism

hyperopia

3

myopia

astigmatism

hyperopia

2

PRK LASEK

LASIK

pIOL

Source: German Commission of Refractive Surgery

Effectiveness (I)

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• myopia hyperopia

• Visual acuity ~ 70% ~ 50-60%

• Precision ~ 70-80% ~ 60%

• LASIK and LASEK show better results than PRK

• pIOL better than laser in severe myopia (> 6D)

Laser clinical success

rates

• Correction-free

• Vision-specific quality-of-life

• Patient satisfaction Patient perspective Poorly studied

Effectiveness (II)

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• Long term stability better in myopia than hyperopia (role of natural evolution with age ?)

• Poorly studied, most frequent follow-up period: 6 to 24 months

Long term?

• Old techniques

• Patient selection less stringent than today

• “Almost all operated are free of correction (although occasional correction may be needed), if not usually a reoperation can be done”

Studies versus Experts

Safety

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• Not free of risk either: keratitis in lenses Glasses and lenses

• LASIK: flap complications

• PRK and LASEK: pain

• pIOL: larger risks than laser

Technique dependent risks

• Loss of 2 lines of BCVA, retinal detachment, cataract, corneal ectasia, keratitis Severe risks

• Dry eyes: 50% in LASIK • Halos and glare: 17% in PRK

Frequent risks

• Well informed? Patients

Cost considerations

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• Generic QoL: no study

• Vision-specific QoL: no large comparative studies Cost per QALY ?

• Theoretical analysis until age of presbyopia (45 yrs)

• Result depends on age and time horizon, spending behavior, type and severity of error, surgery price, successfulness of operation

• Cost saving potential especially compared to lenses and for young persons

Long term cost - patient

Long term cost comparison (I)

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0 2 000 4 000 6 000 8 000 10 000 12 000

PRK

LASEK

LASIK

pIOL

Glasses

Lenses soft daily

Lenses soft monthly

Lenses soft yearly

Lenses hard

Euro

2nd Quartile

3rd Quartile

Variation in type and severity of error, individual

spending behavior, renewal terms, surgery price,

success of surgery... and age/time horizon

Long term accumulated costs

(scenario: age 30 years)

Variation in LT

costs

Long term cost comparison (II)

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Impact of age:

Surgery’s cost saving potential is largest at younger age

0

1 000

2 000

3 000

4 000

5 000

6 000

7 000

8 000

9 000

10 000

20 25 30 35 40 45 Age

pIOL

LASIK

PRK

LASEK

Lenses soft daily

Lenses soft month

Lenses soft year

Lenses hard

Glasses

Long term

accumulated cost

until 45 yrs (€)

Recommendations

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• Objective information for patients on risks, expected outcomes and costs

Clinicians and sickness funds

• Belgian guidelines on indications, contra-indications, and quality norms

• Short and long term registration of outcomes (including correction need) and safety data

• Validated information leaflet for patients

Professional organizations

• Partial reimbursement for small patients group who already benefit from reimbursement of glasses or contact lenses by compulsory insurance

• If validated guidelines, additional target groups with medical need could be considered for reimbursement

Minister of Social Affairs and Health after advice

of competent bodies

Colophon Author(s): Obyn C, Smit Y, Post P, Kohn L, Defourny N,

Christiaens W, Paulus D

Publication date: 20 December 2013

Domain: Health Technology Assessment (HTA)

MeSH: Corneal Surgery, Laser; Keratectomy, Subepithelial, Laser-

Assisted; Keratomileusis, Laser In Situ

NLM Classification: WW 300

Language: English

Format: Adobe® PDF™ (A4)

Legal depot: D/2012/10.273/107

Copyright: KCE reports are published under a “by/nc/nd” Creative

Commons Licence

http://kce.fgov.be/content/about-copyrights-for-kce-reports.

This document is available on the website of the Belgian Health Care Knowledge Centre.

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